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Introduction Injury to the spinal cord or brain stem may damage the nerve cells that stimulate the phrenic nerve, which facilitates contraction of the diaphragm necessary for breathing. Phrenic nerve pacing, which uses and electrode implanted in the chest to stimulate the phrenic nerve, may benefit certain patients who are dependent on a respirator. If your doctor believes that you may be a good candidate for this procedure, he or she may order tests called phrenic nerve EMGs. These tests will usually indicate if phrenic nerve pacing is possible for you. The equipment required for phrenic nerve pacing is much smaller and more portable than a mechanical ventilator. Phrenic nerve pacers improve respiratory physiology because air is drawn into the lungs naturally by diaphragmatic contractions, rather than air forced into the lungs under pressure from a mechanical ventilator.

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Device The device provides electrical stimulation to the muscle and nerves that run through the diaphragm. When the muscle is stimulated, it contracts, causing a vacuum-like effect in the chest cavity that causes air to enter the lungs. When the contraction eases, the air is expelled passively. This process is repeated times per minute. This is essentially the same process as normal breathing.

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Device (cont.) The pacing system consists of: Four Teflon embedded Electrodes: deliver a pulse directly to the phrenic nerve causing the diaphragm muscle to contract. –The quadripolar system sequentially stimulates each of the four electrodes during a given breath, thereby decreasing the number of impulses delivered to a single quadrant of the phrenic nerve by 75% during inspiration. This quadripolar electrode system aims to eliminate the potential for diaphragm fatigue with prolonged pacing and allow for the situation-specific manipulation of pacer settings to meet the needs of an individual through stimulation setting changes by programming modules and the stimulus controller.

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Device (cont.) Platinum/Stainless Steel Leads: connect the electrodes to the receiver and transmitter Radio receivers: translate the radio waves and stimulate the pulses. –The radio receiver has a connector that is screwed into a titanium disc with an axial flange covered entirely by a woven double velour patch, which provides a barrier to infection. –The electrode wires are crimped to the connector and embedded in silicone rubber. External transmitter/antenna assembly (portable control unit): receives its power from 9 volt batteries and sends energy and stimulus information to the patient’s receiver implant.

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Mark IV Transmitter Mark IV Transmitter already in PMA phase has many advantages over the current model (S-232G) Bilateral redundancy, including dual batteries The bilaterally redundant design of the Mark IV provides greater safety than the S-232G transmitter.

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Mark IV (cont.) Amplitude range control Variable Strength of Pulses External breathing rate control The stimulus rate can be adjusted from the front of the device, instead of through the battery compartment as in the older model. Capability for a wider range of stimulus parameters Customized settings for each patient. Capability for asymmetrical parameters Settings can be set independently for each half of the body.

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Mark IV (cont.) Introduction of battery indicators The Mark IV shows the battery level on the front through an easy to read display. Introduction of antenna indicators Like the battery indicators, the Mark IV antenna indicators shows the strength of the signal between the receiver and transmitter. Single circuit board design The single printed circuit board design of the Mark IV is inherently more reliable then the dual circuit board, by providing fewer possible points of failure. Readily available electronic components Off the shelf components are readily available.

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Benefits Over Mechanical Ventilation Breathing is more physiologic Resumes sense of smell, taste and normal speech (although the fixed respiratory rate is a disadvantage for fluent speech) Saves about $1000 per month that would go toward maintenance and disposables for mechanical ventilation Easier for caregivers, Increased quality of life cost effectiveness because patients can live outside of hospitals and the cost of a ventilator and its disposables is eliminated.

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Benefits Over Mechanical Ventilation (cont.) lower infection rate due to reduction in suctioning, elimination of external humidifier and ventilator circuits, and the possibility of tracheostomy tube removal (some patients have had their tracheostomy closed). improved venous return (negative, not positive pressure). normal breathing and speech. ease of eating and drinking. increased patient mobility. unobtrusive use due to the small size of external components and totally silent operation.

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Surgical Procedure 1.A small (4cm) incision is made just above the clavicle. The subcutaneous tissue is dissected down until the anterior scalene muscle has been exposed.

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Surgical Procedure (cont.) 2.Assisted by monopolar electrical stimulation, the phrenic nerve is identified over the scalene muscle. 3.The nerve sheath of the phrenic nerve is carefully exposed for about 1cm through an operative microscope.

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Surgical Procedure (cont.) 4.The electrode lead is place along side the nerve and fixed to the surrounding connective tissues with two sutures.

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Surgical Procedure (cont.) 5.A second incision is made into the anterior upper chest, and the receiver placed subcutaneously. The lead is then tunneled and from the electrode down to the receiver. 6.Both incisions are closed, and the procedure is then repeated on the other side of the chest. Patients are always placed in the Intensive Care Unit for management of their ventilation Prophylactic antibiotics are continued for 48 hours

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Surgical Risks Invasive surgery carries increased risk of infection, as does long hospital stay High risk of damage to the phrenic nerves due to phrenic nerve dissection and electrode placement

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Conditioning Because the patients have atrophied diaphragm muscle, doctors must condition the muscle after the device is implanted before the patients can be weaned from the ventilator. Conditioning is achieved by electrically stimulating the diaphragm for 10 to 15 minute intervals until the muscle is rendered capable of responding to the external battery control of the device for extended periods of time.

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Demographics Approximately 1,000 people have received this procedure world wide. Manufacturer: Avery Labs – FDA approved device 183, ,000 people with spinal cord injury in the Unites States. On average there are 11,000 new cases of spinal cord injury per year. –Nearly 52% of spinal cord injuries are at the cervical level. –Nearly 20% of patients will require mechanical ventilatory support. –Approximately 5% ( per year) are patients who cannot be weaned off mechanical ventilation by natural means and will therefore require chronic mechanical ventilation.

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Costs Cost of procedure is $100, –Cost is covered by Medicare, Medicaid, and many private insurance companies –This might actually be a cheaper alternative to mechanical ventilation, due to decreased cost of care Cost of device: $40,000-$50,000

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“[Phrenic pacing] is a drastic and dangerous procedure. The risks are enormous. Batteries fail. The procedure frees you from the ventilator, but the outcome can be fatal.” - Christopher Reeves. Still Me

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Laproscopic Phrenic Nerve Pacing Technology Developed by Case Western Reserve University bio- medical engineers and physician researchers The new laproscopic diaphragm pacing is a much less invasive, outpatient procedure. Instead of stimulating the phrenic nerve in the neck region, the electrodes are connected to the motor points of the diaphragm. This offers many benefits over the current phrenic nerve pacing, including lowered costs and decreased risks.

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Current Study FDA approved for 35 patients. Currently implanted in 3 patients, including Christopher Reeves. –1st patient to receive device had successful results. –2nd patient the diaphragm was not properly stimulated. The health of the phrenic nerve and the diaphragm muscle were not adequate to support the pacing system. –Christopher Reeves is the 3 rd patient, and has been successful so far.

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Criteria for Eligibility Need to be above 18 years of age. Need to have a high cervical spine injury resulting in tetraplegia. Respiratory failure for the past six months that requires chronic mechanical ventilatory support. Failure of vigorous attempts to wean from ventilatory support. Normal bilateral phrenic nerve function is required. No active cardiovascular disease, no active lung disease, no active brain disease, no significant scoliosis, no chest wall deformity, no obesity.

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Procedure Part I - Implantation 1.Wires are threaded through four small incisions 2.These wires connect 4 electrodes directly onto the diaphragm. The electrodes are not placed directly onto the phrenic nerve. 3.2 stainless steel intramuscular diaphragm electrodes are placed on each motor point of the diaphragm, using a specially designed delivery device that allows for the insertion of the electrodes in the same plane as the diaphragm. (The motor point is the place at which the phrenic nerve attaches to the diaphragm in order to cause movement.)

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Implantation (cont.) 4.A laparoscope and a previously designed mapping procedure is used to determine exactly where on the diaphragm these motor points are. 5.The wires are brought out of the body and connected to an external battery/control that automatically sends mild currents to the electrodes inducing a natural breath. This battery is replaced every week. Breathing is induced 12 times per minute. This is normal breathing rate. This procedure is done on an outpatient basis. Similarly to the current procedure, the patient’s diaphragm requires conditioning.

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Benefits of Laporoscopic Phrenic Nerve Pacing Decreased cost ($10, vs $100,000.00) Much less invasive procedure. Decreased risk-Direct stimulation of the phrenic nerve may damage the nerve. Laporoscopic phrenic nerve pacing does not place the electrodes in direct contact with the phrenic nerve. Less risk of infection because of smaller incisions.

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The Future The enhanced ability for the pacemaker to respond automatically to the body based on physiological signals. For example during speech vs. during relaxation. Internalize the entire device thereby reducing susceptibility to infection. –With use of a battery that can be recharged through the skin. –With a battery that can continue without the need to be recharged for a minimum of ten years. Perhaps with the arising benefits of stem cell technology to regenerate damaged nerves or tissues, the phrenic nerve pacemaker will be made available to patients who are currently considered ineligible for this device due to extensive phrenic nerve damage.